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Last First MIN
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INSTRUCTIONS
This instruction sheet, the Release Form and the Personal History Statement are required to be completed and turned in as requested.
Notarization is required on the Release Form and page 26 of the Personal History Statement.
Items will not be notarized at the Fire D epartment O ffice . This must be completed prior to you turning them in.
Do not fold any of the paperwork!
All responses shall be truthful. OMISSIONS OR INCOMPLETE APPLICATIONS COULD DISQUALIFY YOU.
If unsure of an exact date, use approximate date. (Ex: appx. May 1998)
All juvenile and adult incidents, arrests, convictions and/or illegal drug use must be listed on your application.
Print legibly or type your responses. Use blue or black ink. Do not leave an y blanks.
If additional space is needed for your responses, use only the provided supplemental pages.
Applicant's Signature
R E L E ASE FORM
Name ( Print)
Social Security Number
Date of Birth
To Whom It May Concern:
As an applicant for employment with the City of Chesapeake Fire Department, I hereby authorize the release of such information as may be requested by the City of Chesapeake Fire Department, or its agents. This information may include, but is not be limited to my background, character, education, credit rating, medical and mental health and such other information and supporting documents as may be requested by the City of Chesapeake Fire Department, or its agents.
I hereby authorize the photocopying of any and all such records or information that you may have concerning me.
Signature
Date
City/County of
Commonwealth of
The foregoing instrument was acknowledged before me This day of , 20
Notary Public
-
My commission expires:
Name:Last First M.I
CHESAPEAKE FIRE DEPARTMENT
APPLICANT PERSONAL HISTORY STATEMENT
Page 1POSITION APPLYING FOR: Advanced Life Support Technician
Instructions: FILL OUT THIS QUESTIONNAIRE COMPLETELY AND ACCURATELY. ALL STATEMENTS IN THIS QUESTIONNAIRE ARE SUBJECT TO VERIFICATION. IF THE SPACE PROVIDED IS INADEQUATE, USE THE SUPPLEMENTAL PAGES PROVIDED FOR YOU. TYPE OR PRINT LEGIBLY IN INK ALL RESPONSES. INCORRECT STATEMENTS COULD REMOVE YOU FROM EMPLOYMENT CONSIDERATION.
1. Name: / / Last First Middle Social Security Number
List other names you have used or been known by. Include maiden names, married or adopted names, or nicknames:
2. Present Mailing Address: Number Apt. Street
City State Zip Code
3. Permanent Mailing Address: Number Street
City State Zip Code
Telephone Number: Home: ( ) - Business: ( ) -
Alternate Number: ( ) - E-mail Address:
4. Date of Birth: / / Place of Birth:
City State
5. Are you a U.S. Citizen? Yes: __ No: __U .S. citizenship and proof of such is required for this position.
6. Do you have a valid driver's license? Yes: ___ No: ___If yes, State License Number Expiration
Page 2
7. Have you ever been issued a driver's license from another state other than the one listed above?
Yes: No:
If yes, State License number Expiration
State License number Expiration
8. Have your driving privileges with Virginia or any other state ever been suspended or revoked for any reason? Yes: No:
If yes, which state? Date
Explain reason:
9. Do you have any unpaid parking tickets in this or any other state? Yes: ___ No: ___
If yes, explain. List the city, state, charge and reason why this is outstanding.
10. As a driver, have you ever been involved in a reported or non- reported auto accident?
Yes: No:
If yes, provide the following information:DATE CITY/STATE LIST ANY CITATIONS
ISSUED TO YOUDISPOSITION/
OUTCOME
Page 3List all m o ving traffic citations issued to you and the outcome.
Include all citations from the time you started driving until now. Use approximate dates if exact date is unknown.I n clude all citati o ns i s s ued in Vi r gi n ia and/or other states.
Note: If you pre-paid a fine, you were convicted of that offense.** Citations which no longer show on your record must be listed.List citations in order of occurrence starting with the most recent .
DA
TE
CITY/ STATE CHARGE DISPOSITION/OUTCOME FINE PAID?
YES/NO
1 1 . List all non-moving violations issued to you in this or any other state. (Expired inspection, no seat belt, expired tags, etc.)
DATE CITY/ STATE CHARGE DISPOSITION/OUTCOME FINE PAID?YES/NO
Page 412. Have you ever been arrested, taken into physical custody, been issued a misdemeanor citation.
(Excluding traffic citations), released on your own signature or turned yourself in for any reason?
Yes ___ No ___
Note: Summonses regarding pet or animal offenses must also be listed.
If yes, explain by giving the information below:
DATE AGENCY/LOCATION CHARGE DISPOSITION
Explain in detail all entries above. Use the attached supplemental sheets if necessary.
13. Have you ever been convicted of a felony or misdemeanor?
Yes: No:
If yes, explain by giving the information below:
DATE Agency/Location CHARGE SENTENCE
Explain in detail all entries above. Use the attached supplemental sheets if necessary.
Page 5UNDETECTED CRIMES
14. Have you ever committed, participated in or been present when any of the crimes below were committed or attempted:
Yes No Yes No
Murder Larceny
Arson Shoplifting
Pedophilia Burglary
Rape Manslaughter
Robbery Assault/Battery
Vandalism
Explain any "yes" answers and give dates:
15. Have you ever been questioned by any Law Enforcement authority for any reason other than traffic offenses or motor vehicle accidents?
Yes: ___ No: ___
If yes, give details, date and outcome:
16. Have you ever purchased, sold or been present during the purchase or sale of anything you believed to have been stolen?
Yes: ___ No: ___
If yes, please explain. Give details of the date, the item purchased price, current location of the item and reason you knew/felt the item(s) were stolen.
Page 617. Do you know of, associate with, or reside with any known criminals or convicted felons?
Yes: ___ No: ___
If yes, give details of your relationship with the individual(s) and the criminal conduct/acts they are responsible for:
18. Have you ever used or introduced into your body, b y any means , any illegal drug or substance?
Yes: No:
Complete the drug use chart on the following page. If you have never used any illegal drug, you must indicate so by placing an “X” in the “NO” column by each drug.
Note: Juvenile/Adult "experimentation" MUST be listed!
DRUG YES NO DATE FIRST USED DATE LAST USEDCannabis: (Marijuana, Pot,Weed, Reefer, Mary Jane)
Hashish, Hashish OilCocaine: (Coke, Snow,Candy)Crack: (Freebase Rocks,Rocks)Barbiturates: ( Hypnotics ,or "Downers")Amphetamines: (Ecstasy, Speed, "Uppers")Metha mp hetamine: (Crank, Crystal Met, "Ice")
LSD: or other, (Shrooms,Hallucinogens, Acid)PCP: (Angel Dust, Hog, Peace Pill)Heroin: or other Opiates(Smack, Dope)Inhalants: (Huffing, Sniffing,Bagging)
Anabolic Steroids
Pharmaceutical drugs not prescribed to you
List the name(s) of the pharmaceutical drug(s) not prescribed to you, the reason you used it and how you obtained the drug:
Page 7
19. Is there any other illegal drug, narcotic or substance not listed above that you have introduced into your body?
Yes: No:
If yes, please list it here and include the same information as above:
20. Have you ever sold or purchased any illegal drug?
Yes: No:
If yes, please explain by giving the type of drug, date(s) and circumstances:
21. Have you ever cultivated or manufactured any illegal drug?
Yes: No:
If yes, give detail of incident, date and type of drug (s):
22. Have you ever temporarily stored or "held" any illegal drug, narcotic or substance?
(EXCLUDE ENTRIES FROM QUESTION #18)
Yes: No:
If yes, please explain giving date(s), type of drug and circumstances:
23. Have you ever been present when drugs were bought, sold or used?
Yes: No:
If yes, please give date(s), type of drug and detail of each incident:
Page 8
EDUCATION
24. The Virginia State Code requires Firefighters to possess a high school diploma or its equivalent. Please indicate your current status with regard to this requirement. A college degree is not required for this position.
I possess a high school diploma
I possess a GED certificate
I possess a college degree(s)
Please include the type of degree, name of college and the year degree was attained:
25. List the educational institutions you have attended starting with your high school to the present. Include any colleges, vocational, military, or business schools.
Name of School
City / State Dates of Attendance
Certificates/Degree Earned
Page 9
EMPLOYMENT HISTORY
26. List all jobs you have held within the last 10 years.
Begin with your most current employment. Include militar y service, part time, temporary or volunteer employment.
DO NOT LEAVE ANY BLANKS!
Correct phone numbers and addresses must be listed.
Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time:
Voluntary Dates of Employment: From: To:
Name of Supervisor: Title:
Beginning Salary: Ending Salary:
Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY Reason?
If so, list reason and outcome:
Page 10
Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor: Title:
Beginning Salary: Ending Salary:
Details o f reason for leavi n g ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?If so, list reason and outcome:
Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor:
Beginning Salary: Ending Salary::
Page 11Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Name of employer:
Address, city, state, Zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor:
Beginning Salary: Ending Salary:
Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Page 12
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor: Title:
Beginning Salary: Ending Salary:
Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Page 13Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor Title:
Beginning Salary: Ending Salary:
Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an
acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Name of employer:
Address, city, state, zip:
Area code and Phone number: ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor: Title:
Beginning Salary: Ending Salary:
Page 14
Details o f reas o n for leav i n g ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Name of employer:
Address, city, state, zip:
Area code and Phone number: : ( ) -
Your job title/duties:
Name you were known by:
Full-time: Part-time: Voluntary:
Dates of Employment: From: To:
Name of Supervisor: Title:
Beginning Salary: Ending Salary:
Details of reason for leaving ("Personal Reasons" and "Will discuss with you in person" is not an acceptable reason):
Have you ever been written up, counseled or disciplined for ANY reason?
If so, list reason and outcome:
Page 15
27. Have you experienced periods of unemployment?
Yes: No:
If yes, give the dates:
From: To:
From: To:
From: To:
Reasons for unemployment:
28. Have you ever been terminated, discharged, or asked to resign from any position for derogatory reasons?
Yes: No:
(Include terminations outside the previous 10 years listed)
If yes, complete the following:
Name of employer/company:
Address City State
Supervisor's name/Title
Phone Number
Dates of employment From: To:
Position held:
Details of termination:
Page 16
Name of employer/company:
Address City State
Supervisor's name/Title Phone Number
Dates of employment From: To:
Position Held:
Details of Termination:
Name of employer/company:
Address City State
Supervisor's name/Title Phone Number
Dates of employment From: To:
Position Held:
Details of Termination:
29. Have you ever been forced to resign or been terminated from any position due to conflicts with supervisors, co-workers, schedules, or position held?
Yes: No:
If yes, explain
Page 17
30. Have you ever accepted, taken or given away merchandise, supplies or food from an employer?
Yes: No:
If yes, please complete the following:
Name of Employer: Your position/T Items taken:
What was the value of the item(s):
How many times did this occur?
Dates of Occurrence(s):
Was this done without permission?:
Name of Employer: Your position/T
Items taken:
What was the value of the item(s):
How many times did this occur?
Dates of Occurrence(s):
Was this done without permission?
Page 18
31 Have you ever taken any money from an employer? Yes: No:
If yes: please complete the following:
Name of Employer
Your position/Title:
Amount?:
How many times did this occur?
Dates of Occurrence(s):
Was this done without permission?
Explain:
Name of Employer:
Your position/Title:
Amount?
How many times did this occur?
Dates of Occurrence(s):
Was this done without permission?
Explain:
(
(
Page 19
32. What previous employment did you like the most and why?
33. The least liked and why?
34. Have you ever accepted employment with any Fire or Emergency Medical Service Agency?
Yes: No:
If yes, complete the following:
Agency’s Name:
Address of Agency:
Are you still employed with this agency? Yes: No:
Position/Title:
If still employed reason for seeking other employment?
If not, details of your resignation/termination?
35. Have you ever made application for employment (any position) with this or any other Fire or Emergency Medical Service Agency?
Yes: No:
If you have placed more than one application in with an agency, you must complete the information below for each time. Use supplemental pages if needed.
Page 20
Agency's Name:
Year applied:
State:
Position applied for:
Check all the application phase( s) you completed:
Written Agility B-pad Interview
Background Polygraph Psychological
After which phase were you not selected or disqualified from?
Explain the reason you were given:
Agency's Name: State:
Year applied:
Position applied for:
Check all the application phase( s) you completed:
Written Agility B-pad Interview
Background Polygraph Psychological
After which phase were you not selected or disqualified from?
Explain the reason you were given:
Page 21
Agency's Name: State:
Year applied:
Position applied for:
Check all application phase(s) you completed :
Written Agility B-pad Interview
Background Polygraph Psychological
After which phase were you not selected or disqualified from?
Explain the reason you were given:
Agency's Name: State:
Year applied:
Position applied for:
Check all application phase(s) you completed :
Written Agility B-pad Interview
Background Polygraph Psychological
After which phase were you not selected or disqualified from?
Explain the reason you were given:
Page 22
MILITARY SERVICE
32. Are you registered with the Selective Services? ( registration for military draft)
Yes: No:
If yes, when?
33. Have you ever enlisted in any branch of service for any period of time?
Yes: No:
If yes, fill out the following:
Branch of service Rank at discharge
Dates of service Type of Discharge
34. While in the service were you ever verbally reprimanded, written up, disciplined, been the subject of judicial or non-judicial punishment, charged with Article 15, Captain 's Mast or Court martialed?
(All must be listed, even if it is no longer in your record.)
Yes: No
List the charge(s)
If yes, please give details of each (if multiple occasions) to include the date, detail of
circumstances and outcome (extra duty, drop in rank, pay, counseled, etc.):
Page 23
Personal
35 Do you own an automobile?
Yes: No:
If yes, give make, model, and year:
36. Do you have automobile insurance, assigned risk or certification of compliance with the Uninsured Motor Vehicle Act?
Yes:_______No:_______
38. Marital Status:
Single:_____Married: Divorced:_______Separated:______
39. Name of Spouse :
40. List your parents, brothers and sisters.
Father MotherBro. /Sis. Bro. /Sis.Bro./Sis Bro ./Sis.
41. Give the names of three (3) responsible persons, other than relatives or past employers, could provide information about your character, abilities, experience, personality and other qualities.
1.Name Address Phone number
2. Name Address Phone number
3 . Name Address Phone number
Page 24
42. Begin with your present address and list all previous places you have resided during the last ten (10) years. List the apartment if applicable.
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
Address City/State From: To:
43. As an adult, list all cities and states you have resided in; permanent and/or temporary.
City State City State
City State City State
City State City State
Page 25
Financial (Financial irresponsibility in itself is not an automatic disqualifying factor)
44. Have you ever filed for or declared bankruptcy? Yes: No:
If yes, please give details to include when, where, why and chapter filed.
45. Within the last 7 years, have any of your debts been turned over to a collection agency?
Yes: ________ No:
If Yes, please give details to include when, what account(s), why and whether the debt(s) is clear or balance still due.
46. Within the last 7 years, have your wages ever been garnished? Yes: No:
If yes, please give details to include when, where and why.
47. Within the last 7 years, have you ever had any goods repossessed?
Yes: No:
If yes, please explain when, and what circumstances.
48. Have you ever been delinquent on child support, alimony, income tax or other tax payments?
Yes:___ No:
If yes, please give details to include when, where, why and whether the account(s) is paid in full and/or currently in good standing.
Page 26
I hereby certify that all statements made in this questionnaire are true and complete and authorize the verification of this fact by the Personnel Officer of the Fire Department. I understand that any misrepresentation of material facts, in addition to the omission of information, could subject me to disqualification or termination.
Applicant's Signature
Date
THIS PAGE MUST BE NOTARIZED
City/County of
Commonwealth of_______________________The foregoing instrument was subscribedSworn before me this day of (month) , (Year)
b y_____________________________________________________
Notary Public’s Signature
My commission expires
Use these supplemental pages to include additional information or to further explain any responses from your Personal History Statement.
List the question number you are referencing
INITIAL EACH SUPPLEMENTAL PAGE USED
Initials:_____
Supplemental Page 1
Initials:_____
Supplemental Page 2
Supplemental Page 3
Initials:_______